Of High-Risk Egg-Preparation Practices In Restaurants That Prepare .

J. Food Prot., Vol. 67, No. 7cooked scrambled eggs was associated with SE infection.Other high-risk food-preparation practices may facilitatecontamination of equipment, food worker hands, or fooditems with SE. Contamination of properly cooked eggs bycontact with contaminated items, such as improperlywashed hands, has also been associated with SE transmis sion (1, 12, 14). The risk for SE transmission can be mark edly reduced by use of pasteurized eggs, including pas teurized shell eggs, particularly in entrees containing un dercooked eggs (13, 25).The objective of this study was to identify the preva lence of high-risk egg-preparation practices and evaluaterestaurant egg-preparation policies, including the use ofpasteurized eggs, that may facilitate or hinder transmissionof SE in restaurants that prepare a large volume of eggproducts.MATERIALS AND METHODSThis study was conducted by staff of the EnvironmentalHealth Specialists Network (EHS-Net). The network, created bythe CDC comprises environmental health specialists and epide miologists at federal, state, and local levels who collaborate toevaluate food-preparation practices and policies and their relationto foodborne illness.The EHS-Net selected a convenience sample of restaurantsdefined as facilities that prepare and serve breakfast-type egg en trées to customers throughout all hours of operation in 13 met ropolitan areas in seven states: California, Connecticut, Colorado,Minnesota, New York, Oregon, and Tennessee. Each of thesestates participates in CDC’s Emerging Infections program. Res taurants that serve breakfast-type egg entrées throughout the entireday were selected because they use large quantities of shell eggsand therefore have a large potential for handling SE-infected eggs.Lists of restaurants that met this definition were not available inall states; therefore, restaurants were selected by the most com prehensive list of food-service establishments available to the lo cal regulatory authority. A database of restaurant ownership, num ber of meals served, or seating capacity was not available or easilyobtainable in each state; thus, stratifying selection on these param eters was not possible. Only one restaurant from regional or na tional chains was included per area.After obtaining permission from the restaurant, an EHS-Netspecialist or a trained local environmental health specialist con ducted an on-site interview with either the restaurant manager oranother employee using a standardized questionnaire. The ques tionnaire included both checklists and open-ended questions aboutthe restaurant demographics, food safety policies, and practicesrelated to the preparation of omelets, soft-boiled eggs, hard-boiledeggs, fried eggs, scrambled eggs, poached eggs, French toast, andpancakes. Demographic information included restaurant owner ship (independently owned versus a chain or franchise), whereeggs were purchased, and the type of eggs used in the facility.Data collected on food safety policies and sanitation included in formation about manager food safety certification requirements,storage of shell eggs, the use of pasteurized and nonpasteurizedshell eggs, type of egg entrées prepared, pooling of shelled eggs,and cooking practices. For this evaluation pooling of shelled eggsconsists of breaking and combining more than one shell egg inpreparation of multiple entrées not intended for immediate ser vice. Two open-ended questions were used to identify the locationof shell eggs before cooking and restaurant policy on washing andsanitizing whisks and bowls used to prepare egg entrées. Respons EGG-PREPARATION PRACTICES1445es to the questions about where shell eggs are kept before cookingwere classified into one of three categories: (i) eggs kept in acooling unit before cooking, (ii) eggs stored at room temperaturebefore cooking, and (iii) eggs kept on ice or in a cold-water bathbefore cooking. Responses to the question concerning restaurantpolicy on washing and sanitizing whisks and bowls used to pre pare egg entrées were categorized into three groups: (i) whisksand bowls washed and sanitized at least once in 4 h, (ii) whisksand bowls washed and sanitized once in a 4- to 24-h period, and(iii) responses that did not fall into either of the aforementionedcategories (e.g., utensils were washed and sanitized when needed,with no specific timeline noted). This study did not address theFDA Food Code recommendation 4-602.11, which stipulates thatutensils and equipment may be cleaned less frequently than every4 h if these items are kept in a refrigerated room or in an areamaintained at specified temperatures and that these items becleaned at a frequency specified based on the corresponding tem perature (9).Each interview was followed by a limited observational as sessment that involved measuring the internal temperature of oneuncooked shell egg in a cooling unit, taking final cook tempera tures of three egg entrées, and assessing the location of handwashing facilities. From the batch of stored shell egg in a coolingunit, one egg was selected from the most central location to de termine the internal temperature of an uncooked refrigerated shellegg. The temperature of the refrigerated shell egg was taken byinserting a thermocouple into the shell. Temperatures of an ome let, scrambled eggs, and French toast, prepared with no specialrequests, were measured using a thermocouple. Final cook tem peratures were taken immediately after the entrée was cooked andimmediately before it was served. All site visits were conductedat the restaurants 22 January through 26 February 2002.Data were entered into Epi Info 6.04d (7). Microsoft Excel2000 was used to categorize responses to open-ended questions(2). Data were analyzed using univariate and bivariate analysesperformed with SAS 8.2 for Windows 2000 (23). Prevalence oddsratios (PORs) were used to investigate trends and differences inspecific egg-preparation practices.RESULTSDemographics. A total of 153 restaurants were studied(Table 1). Of these, 63% (96 of 152) were independentlyowned restaurants, and 37% (56 of 152) were corporatechains or franchises. A median of 200 (25% quartile 130;75% quartile 450) meals were served per day. All 153restaurants used shell eggs. Eggs purchased were primarilygrade AA shell eggs (109 of 141) from a wholesaler (124of 153). Many restaurants used additional egg productssuch as pasteurized shell eggs (30 of 148), liquid egg prod ucts (88 of 153), and powdered egg product (9 of 150).Food safety policies. Seventy percent (99 of 141) ofrestaurants reported that at least one manager had receivedfood safety certification. Fifty-five percent (75 of 136) ofrestaurants reported washing and sanitizing their whisksand bowls at least once in 4 h. Nearly 42% (57 of 136)reported washing and sanitizing at least once during a 4- to24-h period, and 3% (4 of 136) of the responses fell intothe other category (Table 2).Egg-preparation practices. Twenty-six percent (39 of152) of restaurants reported holding eggs at room temper ature before cooking, and 5% (7 of 152) kept eggs on ice

1446LEE ET AL.J. Food Prot., Vol. 67, No. 7TABLE 1. Demographics for 153 restaurantsParameterRestaurant ownershipIndependentChain or franchiseMissingaEgg sourceWholesalerLocal producerOtherNo. (%) ofrestaurants96 (63)56 (37)1124 (81)27 (18)2 (1)Shell eggs usedYesNo153 (100)0Grade of shell eggsGrade AAGrade AMissinga109 (77)32 (23)12Pasteurized shell eggs usedYesNoMissinga30 (20)118 (80)5Liquid eggs usedYesNoPowdered eggs usedYesNoMissingaaTABLE 2. Self-reported egg-handling policies and practices in153 restaurantsPolicies and practicesNo. (%) ofrestaurantsManager(s) has food safety certificationYesNoMissinga99 (70)42 (30)12Restaurants pool shelled eggsYesNo83 (54)70 (46)Whisks and bowls washed and sanitizedAt least once in 4 h4–24 hOtherMissinga75 (55)57 (42)4 (3)17Shell eggs held before cookingIn a cooling deviceAt room temperatureOn ice or in cold-water bathMissingaa106 (70)39 (26)7 (4)1Information was not provided and therefore was not included inanalyses.88 (58)65 (42)9 (6)142 (94)2Information was not provided and therefore was not included inanalyses.or in a cold-water bath before cooking (Table 2). Twentypercent (30 of 148) of restaurants used pasteurized shelleggs; 2 of those 30 restaurants used pasteurized shell eggsto prepare each of the eight egg entrées surveyed. The per centages of egg entrées prepared with pasteurized shell eggsversus nonpasteurized shell eggs were similar for all eggentrées. Overall, restaurant chains and franchises used pas teurized shell eggs to prepare egg entrées significantly moreoften (POR 5; 95% confidence interval 2, 11) thandid independently owned restaurants (36% [20 of 56] ofrestaurant chains, 10% [10 of 96] of independent restau rants). Because of small sample size, this POR was notadjusted for modifiers such as volume of eggs prepared orthe number of breakfast entrees prepared with pasteurizedshell eggs.Ninety-five percent (146 of 153) of restaurants reportedpreparing fried eggs. Poached eggs were prepared by 86%(132 of 153) of restaurants. Among restaurants that madeomelets and scrambled eggs, 84% (128 of 153) used shelleggs to make omelets, and 86% (131 of 153) used shelleggs to prepare scrambled eggs. A median of two shell eggswere used to cook one order of pancakes, one order ofFrench toast, an omelet, or one order of scrambled eggs.Shelled eggs were pooled in 54% (82 of 153) of res-taurants: 69% (66 of 96) of independently owned restau rants and 29% (16 of 56) of chains and franchises. Poolingpractices were determined for the preparation of omelets,scrambled eggs, and the combined preparation of pancakesand French toast. The median number of shelled eggspooled was 18 (25% quartile 12; 75% quartile 30) forthe preparation of pancakes or French toast, 48 (25% quar tile 24; 75% quartile 90) for the preparation of om elets, and 36 (25% quartile 18; 75% quartile 90) forscrambled eggs. The median amount of time between thethe pooling of shelled eggs and the cooking of the productwas 4 h (25% quartile 2 h; 75% quartile 24 h) forscrambled eggs, 5.5 h (25% quartile 3 h; 75% quartile 24 h) for omelets, and 6 h (25% quartile 3.25 h; 75%quartile 24 h) for pancakes or French toast.Many restaurants in this study used nonpasteurizedshell eggs to prepare soft or runny egg entrées. Soft orrunny fried eggs were prepared by 78% (94 of 121) ofrestaurants, runny omelets by 42% (44 of 104), and softpoached eggs by 74% (83 of 112) (Table 3). Whether softor runny e

owned restaurants, and 37% (56 of 152) were corporate chains or franchises. A median of 200 (25% quartile 130; 75% quartile 450) meals were served per day. All 153 restaurants used shell eggs. Eggs purchased were primarily grade AA shell eggs (109 of 141) from a wholesaler (124 of 153). Many restaurants used additional egg products